MEDICARE: AILEEN CAROL CANNON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME114340	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	14N3Q	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1841233434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AILEEN CAROL CANNON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 917770
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32891-0001
Country	:	US
Telephone Number	:	813-974-2201
Fax Number	:	813-974-2812

Provider Business Practice Location Address
First Line	:	4202 E FOWLER AVE
Second Line	:	SHS 100
City	:	TAMPA
State	:	FL
Zip	:	33620-6750
Country	:	US
Telephone Number	:	813-974-2331
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	01/04/2024

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